Lessons From Around The World

By Jeffrey Borkan, Charles B. Eaton, David Novillo-Ortiz, Pablo Rivero Corte, and Alejandro R. Jadad doi: 10.1377/hlthaff.2010.0023 HEALTH AFFAIRS 29, NO. 8 (2010): 1432–1441 ©2010 Project HOPE— Renewing Primary Care: The People-to-People Health Foundation, Inc. Lessons Learned From The Spanish Health Care System

Jeffrey Borkan (jeffrey_ [email protected]) is chair of ABSTRACT From 1978 on, Spain rapidly expanded and strengthened its the Department of Family primary health care system, offering a lesson in how to improve health Medicine at the Alpert Medical School, Brown outcomes in a cost-effective manner. The nation moved to a tax-based University, in Providence, Rhode Island. system of universal access for the entire population and, at the local level, instituted primary care teams coordinating prevention, health Charles B. Eaton is director of the Center for Primary Care promotion, treatment, and community care. Gains included increases in and Prevention at the Alpert life expectancy and reductions in infant mortality, with outcomes Medical School and director of the Heart Disease superior to those in the United States. In 2007 Spain spent $2,671 per Prevention Center at person, or 8.5 percent of its gross domestic product on health care, Memorial Hospital of Rhode Island, Brown University. versus 16 percent in the United States. Despite concerns familiar to Americans—about future shortages of primary care physicians and David Novillo-Ortiz is an — adviser for e-health at the relatively low status and pay for these physicians the principles Pan-American Health underlying the Spanish reforms offer lessons for the United States. Organization, in Washington, D.C., and a lecturer in the Department of Library Science and Documentation, Carlos III University, in Madrid, Spain. he recently enacted Patient Protec- than reform in the United States, it is instructive tion and Affordable Care Act in the to analyze Spain’s effort for applicable lessons. PabloRiveroCorteis Director United States outlines a major role In this paper we outline the principles under- General of Quality, Ministry of Health and Social Policy for a strengthened primary care lying the Spanish reforms and the key features of (Spain), in Madrid. system in improving health and the system that grew out of these principles. We Tcontrolling system costs. Although the United describe trends in health care delivery, spend- Alejandro R. Jadad is chief States has not often looked abroad for advice ing, and health outcomes that have occurred innovator and founder of the Centre for Global eHealth on its health care system, the renewed emphasis through the reform period. and holds the on primary care provides an opportunity to learn Research Chair in from other nations that either have historically eHealth Innovation and the ’ Rose Family Chair in emphasized primary care s role in health care, History And Context Supportive Care. He is a have recently strengthened their primary care Following a protracted period of isolation under professor in the Departments systems, or have created horizontally and verti- the dictatorship of Francisco Franco (1939–75), of Health Policy, Management, cally integrated health care systems through Spain underwent a period of rapid renewal. The and Evaluation and of Anesthesia, and in the Dalla reforms. nation adopted a democratic style of govern- Lana School of Public Health, Spain, although often overlooked,1,2 provides ment, joined the European Union, liberalized University Health Network an example that could be instructive for other its markets, and grew its economy to a point and , in nations seeking to strengthen their primary care where it has become one of the twelve largest Ontario, Canada. systems. economies in the world as measured by gross The Spanish health system has undergone domestic product (GDP).8 rapid transformation, achieving impressive im- The post-Franco era was also marked by rapid provements in health status outcomes in a short reorganization and transformation in health time with relatively modest investments.2–7 care and social services. On June 4, 1977, the Although the Spanish health care system reform Ministry of Health and Social Security was cre- took root in a different sociopolitical context ated by the first democratically elected

1432 Health Affairs August 2010 29:8 government. The following year, the Spanish for which there are major access problems, such Constitution of 1978 declared the right of every as preventive gynecological care.11 citizen to health protection and care and re- The contemporary National Health System of quired the creation of a universal, general, and Spain incorporates both public and private free national health system that guaranteed health care systems. It provides universal cover- equal access to preventive, curative, and rehabili- age for citizens, foreign nationals—including tative services.9–14 Managerial and administrative undocumented immigrants within Spanish na- power over health services was transferred to the tional territory—as well as nationals of European Spanish National Institute of Health (Instituto Union (EU) Member States and non–EU Nacional de Salud, or INSALUD). Member States where rights are recognized by A rationale for a coherent health care structure applicable laws, treaties, or conventions.10–12 The was determined by first mapping and analyzing distribution of health care powers and duties, as all health care services within Spain on the level originally established by the 1978 Spanish of Autonomous Regions or Communities—sim- Constitution, was further clarified by the 1986 ilar to states in the United States. In 1981, juris- General Health Act and subsequent legislation. diction over health care was decentralized from The central government has power and the Spanish National Institute of Health to responsibility for the basic principles and co- Spain’s seventeen Autonomous Communities. ordination of health affairs, setting certain na- A strategy for care delivery was formulated by tional standards and pharmaceutical policy. It several Autonomous Communities using pri- also is in charge of the National Institute of mary care centers, primary care teams, service Health Management, which is responsible for coordination, and personalized services.13 the management of rights and obligations of In addition, the creation of family medicine as the National Institute of Health (INSALUD), a medical specialty contributed to higher stan- health benefits in two Spanish enclaves in North dards and a distinctive professional identity for Africa, and a variety of activities necessary for the primary care physicians.13 The transformation implementation of the key health laws. The was further formalized with the passage in Autonomous Communities control health plan- 1986 of the General Health Act (Ley General ning, public health, and the management of de Sanidad), enabling the creation of an inte- health services, while local councils oversee grated National Health System and agreement health and hygiene and collaborate in the man- on the range of health services that would be agement of public services.11,14 publicly funded throughout the country.9–12 Each Autonomous Community further distrib- The 1978–86 transition in Spain’s health care utes its health care services into Health Areas and system included a major shift in basic financing Basic Health Zones according to demographic, from a social insurance model to one that is tax- geographic, cultural, epidemiological, employ- based and the creation of a robust primary care ment, and other criteria. The key aim is to guar- sector. These two developments marked a dra- antee service proximity to users. Health Areas matic departure from the Franco era, when em- are responsible for the management of facilities, phasis was placed on the development of a social health services, and benefits within their geo- security–style system designed to provide spe- graphical limits. Each is mandated to cover a cialized services through a national network of population of 200,000–250,000 inhabitants.12 large hospitals. A Health Area is composed of several Basic The new emphasis on primary care was linked Health Zones, which constitute the framework to the decision at the outset of the transforma- for primary health care delivery. tion to provide universal access to health services Primary health centers are based in Basic for the entire population. The shift from social Health Zones, while each Health Area is assigned insurance contributions to taxes was accompa- a general hospital for referral to specialist nied by other major economic reforms, includ- care.11–13 Basic Health Zones are the smallest unit ing the separation of providers from purchasers of health care organization. They are usually and the conversion of hospitals to foundations organized around a single primary care team, or trusts.3,14 covering 5,000–25,000 inhabitants, and they co- Although most primary care in Spain is now ordinate prevention, promotion, treatment, and publicly funded, it is estimated that 15 percent of community care activities.12 the population holds private supplemental in- surance that covers benefits beyond those pro- vided by the National Health System.15 Tracking Progress: Outcomes And Supplemental health insurance may cover serv- Spending ices not covered by the public system, such as The 1978–86 transformation of Spain’s health dental care, or may facilitate entrée to services care system facilitated noteworthy progress in

August 2010 29:8 Health Affairs 1433 Lessons From Around The World

the delivery of high-quality and cost-effective Spanish health care transformation was to rely care. In 2007 Spain spent $2,671 per person, on a robust primary health care system, similar or 8.5 percent of gross domestic product in scope and infrastructure to the concept of the (GDP) on health care—which was below the aver- patient-centered medical home now taking hold age of 8.9 percent for countries in the Organiza- in the United States.17,18 Primary health care is tion for Economic Cooperation and Devel- characterized by extensive accessibility, with suf- opment (OECD). That amount compares to the ficient technological resources to deal with $7,290, or 16 percent of GDP, that the United common health problems. States spends on health care.4 When the reform started in 1978, Spain had a Health outcomes also improved dramatically primitive primary care structure that involved a during the two decades between 1986 and 2006 sparse national network of consultorios—doc- (Exhibit 1). By 2007, Spain ranked sixth among tors’ offices. The typical consultation generally thirty OECD industrialized democracies in life lasted around one minute, and general practi- expectancy after birth—84.3 years for women tioners limited their role mostly to rushed re- and 77.8 years for men—compared to the U.S. quests for basic laboratory tests and chest x- rank of twenty-fourth—80.7 years for women rays, medication prescriptions, and referrals to and 75.4 years for men.5 Spain’s infant mortality specialists working in ambulatory clinics or hos- rate as of 2009 is also among the lowest in the pitals.19,20 General practitioners and nurses world, ranking seventeenth out of 224 nations, working in the community had neither the time whereas the United States ranks forty-fifth.7 The nor the mandate to engage in health promotion two decades of reform also witnessed drastic re- or disease prevention activities. ductions in premature deaths from specific con- Spanish health system leaders set as a goal that ditions. For example, between 1986 and 2006, there be a primary care center within a fifteen- there was a marked decrease in mortality from minute radius of any place of residence.11–13 diseases of the circulatory system from 322.1 to To assist with the provision of such services, 159.0 per 100,000 population, adjusted for age. the specialty of family and community medicine Deaths from diabetes mellitus also declined dur- was created in 1978, with the mission to promote ing the same period, from 19.8 to 12.5 per comprehensive health care, including disease 100,000 population, adjusted for age.16 prevention and health promotion. From 1986 on, intensive strategies of institutional reform and capacity building13 were introduced to build Underlying Principles And Key a primary care infrastructure to meet the goals of Features comprehensive care. This included the creation We describe eight major principles that underlie of highly qualified, multidisciplinary primary the primary care system’s main features. These care teams, backed by sophisticated workforce principles were critical to the success of the and professional development programs, proc- transformation, and many are applicable to ess redesign, decentralized service provision, the United States and other countries around and a progressively stronger information and the globe. communication system. Principle 1: Stronger Primary Care The primary care teams are composed of gen- Spain’s National Health System is structured eral practitioners—both those with and without into two levels: primary health care and special- specialized training in family and community ist health care. One of the central tenets of the medicine—pediatricians, nurses, administrative

EXHIBIT 1

Selected Health Indicators, Spain And United States, 1986 And 2006 1986 2006 Indicator Spain U.S. Spain U.S. Life expectancy, years (combined for men and women) 76.4 74.7 81.1 78.1 Infant mortality, deaths per 1,000 live births 9.2 10.4 3.8 6.7 Premature deaths (standardized rates) per 100,000 people Cancer 159.1 183.9 151.2 157.9 Cerebrovascular disease 103.5 53.1 43.3a 33.4a Acute myocardial infarction 53.4 98.5 33.1a 37.9a Respiratory system 63.7 62.3 58.6a 59.8a

SOURCE Organization for Economic Cooperation and Development (OECD), Statistics Portal. a2005 data.

1434 Health Affairs August 2010 29:8 sulted from the extensive reforms, were available The goal of having a to 81 percent of the total population in 2000, with the remainder covered by the old system primary care center of individual doctors and nurses.12 By 2008 the number of public primary care centers in Spain within fifteen minutes had grown from 30 at the time of the reform to of every citizen has 2,913. In addition, there are 10,178 basic medical centers in small towns, mostly in rural areas, nearly been met. where essential health care services are provided to the local population by primary care teams. The goal of having a primary care center within fifteen minutes of every citizen has nearly been met. In 2008 these centers were staffed by 34,126 primary care physicians, of whom 81.8 percent staff, and, in some cases, social workers, mid- were general practitioners specializing in family wives, and physical therapists.9,19,20 and community medicine and 18.2 percent were Primary care teams in the public system are pediatricians.10 All told, there were more than formally assigned a comprehensive set of func- 300 million medical consultations in primary tions that include a broad range of services: gen- care in 2006, compared to 25.3 million emer- eral medical care—treating children, adults, and gency visits and 73.7 million specialty consulta- the elderly—twenty-four-hour availability, diag- tions.11,12,19 In real terms, this means that primary nostic services, minor surgery, family planning, care teams now handle more than 70 percent of prenatal and obstetric care, pharmaceutical pre- all health care visits in the country. scriptions, home visits, certifications, ambu- Specialists in Spain are almost twice as numer- lance services and patient transport, nursing ous as primary care physicians.11–14 Formal link- care and palliative care, preventive services ages at the Health Area level bind primary care and health promotion, and specific services for physicians and specialists together in opera- the mentally ill.12 tional units. Access to specialists is achieved ei- All health professionals working at primary ther through referral from the patient’s primary care centers, including physicians, are salaried. care physician, via emergency or accident de- General practitioner salaries generally contain partment visits, or, for some specialties, through two elements: a larger fixed payment and a direct patient self-referral. Primary care physi- smaller incentive payment. The incentive pay- cians are not saddled with a “gatekeeper” func- ments vary between Autonomous Communities, tion, however. In fact, all patients are entitled to but they may be based on elements such as num- second opinions and referral to specialty care if bers of patients assigned to a physician’s prac- they desire. tice, fulfillment of objectives, patterns of pre- The transformation of primary care has re- scription, and pay-for-performance.9,19,21,22 quired investments of one-sixth to one-seventh Everyone covered by the Spanish National of the total public spending on health.23 Health System is entitled to a package of primary Although there is dynamic private medicine in care services, which are funded by taxes. This other sectors in Spain—consisting of specialists, package includes acute and chronic medical hospitals, and other providers—primary health care, health promotion and preventive care, care is largely publicly funded.12 As can be seen in rehabilitation, and home-based care, all free of Exhibit 2, public spending on primary health charge. services nearly tripled between 1988 and 2003, Since the 1986 General Health Care Act came from 2.1 billion euros to 5.9 billion euros. into force, patients have had the right to choose Despite the extensive and expanding nature of their physician within their Health Area. In 1993 primary health care in Spain, public health this right was expanded to include the ability of spending on primary care as a percentage of total patients to choose a primary care physician public expenditures on health decreased, from working in another Health Area. The sole re- 17.0 percent in 1986 to 14.3 percent in 2003. quirement for such switches is that the chosen Meanwhile, spending on hospital and special- physician agrees to accept the person as a pa- ized services remained above 40 percent of total tient. There is some variation between Autono- spending.23 mous Communities, however, and some have Principle 2: Voice For Citizens Another core developed more detailed patient choice regu- tenet was to give people a voice in health care lations.9,12,19,20 decision making. This principle was imple- Results of the reform efforts have been dra- mented in several important ways. Public forums matic. Primary care teams, a concept that re- were and still are used to get public input into

August 2010 29:8 Health Affairs 1435 Lessons From Around The World

EXHIBIT 2

Total Public Spending On Health In Spain, By Sector Of Spending, Billions Of Euros, 1988–2003

Consolidated total Hospital and specialized services Primary health services Public health services Billions of euros

SOURCE Ministry of Health and Social Policy, Spain. NOTE Datafor2002and2003arepreliminaryestimates.

health system at the local and ment systems for each citizen.25 Patients’ com- regional levels. Not only do these forums provide prehensive electronic health records can be a powerful means for public engagement, they activated by an individual health insurance card also allow for expectations to be managed by (Tarjeta de Salud Individual), swiped on a card communicating about time and resource con- reader, to supply health care providers with in- straints. formation on the patient’s medical history, med- Technologically sophisticated systems are ications, and important diagnostic test results. spreading throughout the country to allow pa- The objective is to have each citizen assigned a tients to communicate with health professionals, unique personal identification code that will managers, and policy makers through many dif- identify him or her throughout the entire Na- ferent pathways.19,21,24–26 In many regions, health tional Health System, with all Autonomous Re- information is now conveyed via phone, e-mail, gions sharing data.21,24,25 Currently, all Spanish Web, TV, DVD, and text messaging. A compre- citizens have individual health insurance cards, hensive scheduling system for each Autonomous and 98 percent of primary care consultations are Region allows patients to schedule appoint- supported by them.25,27 These cards will be acces- ments to meet health care needs for themselves sible in every region by the end of 2010.25 and their families. By 2007, 97 percent of all consultations in Technology is being increasingly used to make primary care centers were supported by elec- information on quality indicators of providers tronic health record management software, and hospitals available online. The goal is to and 64 percent of centers had tools to support strive for high levels of transparency and addi- online patient referrals.19 In the next phase of the tional opportunities for public engagement in National Health System development, an inte- quality improvement efforts at local health care grated electronic health record system is being facilities.19 Some Autonomous Communities, instituted throughout Spain using both central- like Andalusia and Catalonia, are well on their ized and decentralized platforms, to promote the way to creating electronic health records that free exchange of information across regional integrate all health and administrative data boundaries.25 This effort, known as Online and appointments into a single, highly acces- Health (Sanidad en Linea), is led by the Spanish sible, uniform system, for use by both health Ministry of Health and Social Policy. professionals and patients.21,26 Because of its impressive results with a rela- Principle 3: Electronic Health Records All tively limited budget, this initiative was selected of the Autonomous Communities have worked to in 2008 as the best technological project among computerize their health centers and services those supported by the national government of during the past fifteen years, creating unified Spain in all sectors.19,25 The Online Health databases, comprehensive electronic health rec- project received more than 250 million euros ords, and other health care information manage- per year between 2006 and 2008, equivalent

1436 Health Affairs August 2010 29:8 Spanish Ministry of Health and Social Policy The systemwide directly negotiates the cost of medications with large multinational corporations.29 This strategy approach to health has proven effective in reducing the cost of phar- maceuticals while providing a viable business care reform has been model for the pharmaceutical industry, and it critically important to has been used similarly for new medical technol- ogies.19 Although Spain is suffering from the success. high cost of medical technology and pharma- ceuticals, like many other nations, it has been identified as a country able to incorporate inno- vative medicines into its public health care system.30 Principle 5: Regional And Local Levels to US$296–US$400 million, using the exchange Although health care strategies are set nation- rates at that time. The Digital Medical Record ally, they are implemented and coordinated re- Project in the National Health System aims to gionally and locally. This is important, as the provide citizens and health professionals with flexibility allowed by local autonomy permits lo- access to clinically relevant health information cal authorities to be responsive to local needs from anywhere in the country, with the assur- and conditions. ance that access to data is restricted to author- An example of this was a National Health Sys- ized personnel.25 tem quality improvement initiative begun in Principle 4: Community Pharmacies The 2007. At that time, the National Health System creation of a countrywide system of community identified six major areas for quality improve- pharmacies has been another key component of ment: health promotion and prevention, increas- the renewal of the National Health System. Be- ing health equality and reducing disparity, health tween 1976 and 2008, the total number of phar- workforce planning, clinical excellence, health macies increased from 14,533 to 21,057, with information technology, and transparency. large numbers outside of the Autonomous Com- The Quality Plan of the National Health System munities’ capitals.28 Notably, greater equity and then developed twelve strategies with specific access to pharmacies has been achieved through goals designed to increase quality and efficiency, establishing demographic, geographic, and and to reduce unnecessary costs and wait times other needs-based regulatory criteria for open- for patients. These strategies were designed with ing new pharmacies.21 Although the Autono- input from local authorities and carried out at mous Communities are responsible for the the national, regional, and local levels.31 Each planning of pharmacy networks, there are many Autonomous Community was able to set its similarities between regions, and all must abide own goals, with some such as Catalonia focusing by government policy.12,13,29 on e-health,26 while others took on chronic dis- The system provides all medications free to ease management.32 patients older than age sixty-five, pensioners Principle 6: Best Practices Another impor- (who could be as young as sixty-one) and their tant aspect of the transformation of the health beneficiaries, and people with permanent dis- system in Spain has been the use of multiple abilities. No patient with a chronic disease is demonstration projects to develop best practices denied needed medications. Copayments are for the redesign of clinical processes and to share generally required for nonpensioners and their lessons learned throughout all Autonomous beneficiaries under age sixty-five.12–14 Addition- Communities.33 The ultimate goal is to generate ally, there are three levels of reimbursement for knowledge with which to improve health orga- prescription drug expenses: (1) 100 percent nizations, as well as facilitating collaboration reimbursement for hospital pharmaceuticals or among organizations and the general public. specialized care patients; (2) 90 percent reim- For instance, in Andalusia, the largest Autono- bursement for pharmaceuticals for the manage- mous Community, highly prevalent health con- ment of chronic illnesses such as diabetes, ditions—including cases of multiple chronic asthma, and epilepsy; and (3) 60 percent reim- diseases—are managed following integrated care bursement for the majority of prescription-only paths. These focus on the care that patients pharmaceuticals.14 should receive overall, rather than the contribu- The provision of necessary medications has tion of each specialty or caring function inde- been an important factor in reducing prevent- pendently. Care paths are increasingly enabled able illness and death. To facilitate providing by online platforms, such as the Observatory of often-costly medications to its citizenry, the Best Practices for Complex Chronic Disease

August 2010 29:8 Health Affairs 1437 Lessons From Around The World

Management—known as OPIMEC, its Spanish acronym—designed to promote national and It is possible to international collaborative efforts to accelerate health system reform.19,32 transform primary Principle 7: Systemwide Approach The sys- temwide approach to health care reform has care and still achieve been critically important to success. Many U.S. impressive reform efforts have focused on one or two levels or nodes in the health care system—such as improvement in the physician groups, physician practices, hospitals, or specific health insurers. In contrast, the Span- health of the ish efforts have involved inclusive initiatives that transcend traditional geographic, sector, and in- population. stitutional boundaries, backed by local and regional implementation plans.12,13,19,24,25,31 An example is the Online Health system de- scribed above, funded jointly by the Ministry of Health and Social Policy; the Ministry of Indus- try, Tourism, and Commerce; and each of the seventeen Autonomous Communities. This ap- proach recognizes and takes advantage of the Limitations, Shortcomings, And fact that all actors in the system are connected Ongoing Problems to and dependent on one another, and it pro- As with all complex social organizations, the motes horizontal and vertical health care inte- Spanish health care system has major limita- gration. tions, shortcomings, and problems. Many of Principle 8: Sustained Commitment Per- these are a result of broad environmental influ- haps the most important principle has been ences and mirror problems in other systems. the emphasis on bipartisan, sustained commit- These problems will be the focus of ongoing ef- ment by Spain’s political leadership to providing forts to make the system more adaptable and universal access to high-quality health care for flexible so that it can be responsive to new prob- all Spanish citizens. In times of both economic lems as they arise. success and hardship, stable funding to health One example of such difficulties is pressure to care was sustained over a twenty-year period. As provide high-quality universal care in the face of noted above, there has been consistent growth in ever-increasing costs and competition for finan- public spending on primary health services and cial resources.9 This pressure has been exacer- health care. bated by population growth—both from internal More than 70 percent of Spain’s population in growth and through immigration—an aging 2008 perceived that the health care system works population, and the global financial crisis.30,35 well or fairly well, and nearly 85 percent rated the Another example is the insufficient primary attention they received from family physicians as care physician workforce. The rapid expansion good or very good.34 Even so, the Ministry of of primary care in the 1980s and 1990s out- Health and Social Policy recently launched a na- stripped the ability of the Spanish infrastructure tional cooperative discussion on the future of the for graduate education in family and community health system. medicine to provide adequate numbers of train- Ministry officials are seeking support from all ees. Spain had only 50 general practitioners per key constituents—including regional govern- 100,000 inhabitants in 1991—one of the lowest ments, health professional associations, and ratios in the European Union.12 Efforts have been political parties—for a concerted agenda. The forthcoming to address these primary care work- agenda includes promoting optimal levels of force deficiencies. After some initially slow quality, equity, and innovation; strengthening progress, the number grew rapidly to 100 gen- public health policy-making processes; improv- eral practitioners per 100,000 inhabitants by ing human resources management; and guaran- 2008.36 As in many other Western countries, teeing the financial sustainability of the system. there remain concerns about future deficits of Critical support has come from the Interterrito- primary care physicians.36 rial Council for the National Health System A third example is the relatively low status and (Consejo Interterritorial del Sistema Nacional pay for primary care physicians, as compared de Salud), which is presided over by the minister to European standards.12,37 A 2004 study that of health and social policy and includes all sev- reported on payment levels for primary care enteen regional ministers of health. physicians in seven European and five English-

1438 Health Affairs August 2010 29:8 speaking Western countries found Spanish com- ful to countries and regions as they embark upon pensation levels to be substantially lower. Addi- their own plans for health care transformation. tionally, there are differences in pay between Although other countries have undergone trans- Spanish general practitioners and their special- formation, including the United Kingdom and ist counterparts—with GPs earning less than spe- Canada, Spain stands out as a case of recent, cialists.37 rapid innovation, with transformation achieved A fourth example is the increasing percentage in less than a single generation. A tenet of the of patients entering the Spanish health care renewed Spanish system is that it is based on system through accident and emergency depart- primary care. The resulting health outcomes ments of hospitals, rather than through primary are consistent with a growing body of evidence care.38 Although there may be multiple explan- in favor of this approach from around the ations for this phenomenon, it signals a failure of world.40–42 the health care system, including patient educa- Finally, the Spanish example points out the tion, and will have to be dealt with effectively in critical nature of sustained, bipartisan leader- the long term to hold down costs. ship and commitment toward health care trans- Fifth is insufficient visit time. Among six Euro- formation. Rising health care costs and the need pean countries, Spain and Germany have the for improved health outcomes are truly global, shortest consultation times.39 long-term issues. The Spanish experience has shown that it is possible to transform primary care, as part of an overall health care transfor- Discussion And Potential mation conducted in a short time frame with Implications modest investments, and still achieve impressive The best practices, solutions, and insights improvement in the health of the population. ▪ gained from the Spanish experience may be help-

The initial draft of this article benefited affairs. Any views expressed in this governmental opinion on the Spanish or from input by Bernat Soria, then the articlereflecttheauthors’ scientific and U.S. health system. Spanish minister of health and consumer academic perspectives, not a

NOTES

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1440 Health Affairs August 2010 29:8 ABOUT THE AUTHORS: JEFFREY BORKAN, CHARLES B. EATON, DAVID NOVILLO-ORTIZ, PABLO RIVERO CORTE & ALEJANDRO R. JADAD

also directs the Heart Disease deputy minister of strategic Prevention Center at Memorial planning and coordination for the Hospital of Rhode Island. Eaton Regional Presidency of the Jeffrey Borkan is has more than twenty-five years of Government of the Balearic with the clinical experience, has received Islands, and deputy minister of Department of several outstanding teaching and planning and finance for the Family Medicine, mentoring awards, and has Ministry of Health of the Balearic Warren Alpert published more than 100 scientific Islands. Medical School, papers. Brown University.

Jeffrey Borkan is chairman and research professor of family medicine at the Warren Alpert Medical School of Brown Alejandro R. Jadad University. He is also the board is with the chairman for the Association of David Novillo-Ortiz University Health Departments of Family Medicine. is with the Ministry Network and the University of He is active in both family of Health and Social Policy, in Toronto. medicine and medical Madrid, Spain. anthropology, and he has Alejandro R. “Alex” Jadad is a conducted research among David Novillo-Ortiz is an adviser professor in the Departments of minorities and the underserved, for e-health at the Pan American Health Policy, Management, and principally in the United States and Health Organization (PAHO), in Evaluation and of Anesthesia, and Israel,aswellasinHondurasand Washington, D.C. He is also a the Dalla Lana School of Public on the Pacific island of Tonga. lecturer and researcher at Carlos III Health at the University of Borkan’s research interests include University in Madrid. Until Toronto, in Ontario, Canada. He is health policy, physician-patient recently, he served as an executive the founder of the Centre for relationships, low back pain, and adviser in the Ministry of Health Global e-Health Innovation and medical narratives. and Social Policy, Spain. holds the Canada Research Chair in E-Health Innovation as well as the Rose Family Chair in Supportive Care at the University of Toronto. Jadad is also chairman of the Charles B. Eaton is Canadian Association for People- with the Centred Health’sAcademic Department of Pablo Rivero Corte Research Collaborative, and of the Family Medicine, is with the Ministry Global People-Centred eHealth Warren Alpert of Health and Innovation Network. Medical School, Social Policy, in Borkan and his coauthors were Brown University. Madrid, Spain. “drawntotheSpanishhealthcare Charles B. Eaton is a professor of Pablo Rivero Corte is Director system because it represents an family medicine and community General of Quality in the Ministry example of rapid transformation health, specializing in of Health and Social Policy in with impressive outcomes and epidemiology, at the Alpert Medical Spain. He is responsible for relatively lower costs,” Borkan School. He joined the faculty in developing the strategic health said. “Also, Spain is not a 1990 and was associate residency Quality Plan for the country, polarizing example for U.S. director, predoctoral director, including clinical excellence audiences like the U.K. or Canada, research director, and interim strategies, advanced information and has the benefit of having both chairman of the department before systems, and e-health. He has been a public and private health sector.” becoming director of the Center for deputy minister of the Ministry of Primary Care and Prevention. He Finance and Economic Affairs,

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